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SERVICE REQUEST �y <br /> Type of Business or Property FACILITY ll]# <br /> �S SERVICE REQUEST# <br /> OWNER QPERATORE L / <br /> B[LUNG PARTY 0 <br /> FACIL1rY NAM[ <br /> SITE ADDRESS _ <br /> =SV*@t IXrectlon "/V <br /> Mailing Address (If Different from Site Address) SVurgame Trp` <br /> Sort■t <br /> Cmr <br /> V D STATE zip _ <br /> PHONE#'l �S <br /> APN# LAND DISE APPLICATION# <br /> ( <br /> PHONE#2 EXT. BOS:DISTRICi <br /> LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR <br /> Do /VBUING PAR�� <br /> BUSINESS NAME PHONE# , <br /> MAILING ADDRESS # <br /> FAX <br /> Cmr �' (�CJX 9 ��0.- 2��8 <br /> I f2 I STATE <br /> zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner.operator or authorized agent of same, acknowledge That all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMS10N hourly Charges associated with this projector activity will be billed to me army business as identified on this conn. <br /> I also certify that 1 have prepaZthislication and tha ork to be performed will be done in accordance with all SAN JOAQUIN CDurrrY Ord rlmlcu Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: 9 —� –o/ <br /> DATE:__. [_ _ <br /> PROPERTY I BUSINESS OWNER 0 OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT � ` <br /> IlAPPLcAvr is mol rho 8� rrr <br /> proof of aulboadwr to arpn Is mqur Titre <br /> AUTiiOR[ZATEOh TO R�LEASt INFORMATION;When applicable,1.the owner or operator of the property located at the above site address,hereby authafte the release of <br /> any and all results,geotechnical data andlor envirorlmentallsile assessment information to the SAN JOAWLN COUNTY PUBLIC HEALTH SERVICES EnmoNMCNTAL HEALTH OMSION as soon <br /> as it Is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> /V/Z A O�Di�1 N rr r D '5l/ <br /> COMMENTS: LTX �Z <br /> •r� c�/`/� [')1 <br /> SLP <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: Urs <br /> 0 <br /> f r I)A7E: <br /> ASSIGNEDT0: EMPLOYEE#: �/ L./L-� DATE: <br /> Lo r ! <br /> Data Service Completed (if already completed}: r � <br /> U- SERVICE CODE: S 2 P!E: <br /> Fee Amount: Li Amount Paid # <br /> � Payment Date �- <br /> PaymentType r) Invoice#' <br /> tr Check# i ' 1 i Received By: <br />